Patient Information s11

INDIANA LEAD AND HEALTHY HOMES PROGRAM LEAD POISONING HOME VISIT FORM

RETURN WITHIN 10 BUSINESS DAYS Interviewer: Date of Home Visit:

Agency:

Person Interviewed: Relationship:

PATIENT INFORMATION Last Name: First Name:

Address: Medicaid#:

City: ,IN Social Security#:

Zip Code: Length at Residence: ____Years ____ Months

EBL LEVEL: Venous / Capillary BLL TEST DATE:

Is this an Initial Home Visit?: Yes_____ No_____ Birth Date: Age: Sex: Male _____ Female _____

RACE: African American_____ Native American_____ Asian/Pacific Islander_____

Caucasian _____ Multi-Racial_____ Other_____ Unknown_____

Ethnic Origin: Hispanic______Non-Hispanic______Unknown______

Parent/Guardian Name: Relationship to Child:

Home Phone: (______)______Work Phone(_____)______

Cell Phone: (______)______

Is mother pregnant? Yes_____ No_____

Who to contact if you move?: Name: Phone Number:

List where child has lived in the past 12 months:

Rev. 8/16/2011 1 Address City/State County Years/Months

Other household members: Note children less than seven years of age, pregnant women and adults employed in jobs that may expose them to lead. Name Relationship to Date of Birth Age Occupation Child

List where child spends more than six hours a week, other than home: Name of Location Address Phone Number Time Spent at Location

MEDICAL INFORMATION Has child ever been hospitalized?: Yes _____ No _____

If yes, when and why?:

Does child have any other medical conditions or health issues?:

Does child have any behavioral issues/problems?:

Physician/Provider/Clinic Name:

Address: City: ,IN

Zip Code County: Phone Number:

Rev. 8/16/2011 2 Do any adults in the household work in a lead industry? (Lead smelters and foundries, radiator repair shops, battery manufacturers, construction, glass and ceramic industries, etc…) Who? What Occupation? How long Is clothing Is shower Is routine employed changed taken before blood lead there? before leaving test given? leaving work? work?

Does anyone in the home have a hobby involving lead? (Soldering, stained glass, bullet making, ceramics, working on cars, etc…)

Does anyone in the home use any off brand or imported cosmetics? (Nail polish, lipstick, skin cream, eyeliner, etc…)

Does family use home remedies?

Who owns home? Name: Phone:

Address: When was the house built? What type of Single Family _____ School _____ Unknown _____ dwelling? Multi-Unit _____ Day Care _____ Other ______What type of occupancy? Owner Occupied _____ Public Housing_____ Unknown_____

Private Rental _____ Section 8_____ Other_____

NOTES:______

Y=YES and N=NO (circle the one that applies)

Rev. 8/16/2011 3 Y or N Does child crawl? Y or N Does child eat or chew on non-food items (paint chips, ashes, cigarette butts, batteries, paper, pencils/crayons Y or N Does child eat dirt? Y or N Does child suck on batteries or other materials containing lead compounds? (lacquers, pipe sealants, putty, gasoline, oil, epoxy resin, dyes, etc…) Y or N Is there peeling paint inside or out or evidence of lead fallout on window sills, railings, porches, and outside steps or peeling paint on neighbors homes, garages or fences? Y or N Has residence been remodeled in the last six months? Y or N Does child have exposure to homemade or imported ceramic dishes? Y or N Does family store food in open cans and/or ceramic containers especially acid foods such as fruit juices, vinegars, homemade wines, etc…? Y or N Is dwelling located within two blocks of a freeway or major thoroughfare? Y or N Is dwelling located near a lead related industry? Y or N Is there peeling paint where child likes to play? Where, on the inside and outside of home, does child like to play? Where do you think child is getting lead exposures? How often does child get protein foods? (meat, eggs, peanut butter, beans, etc…) How often does child get calcium rich foods? (milk, cheese, green leafy vegetables) How often does your child get fruits and vegetables? How often does your child get breads and cereals? How often does your child get sweets and soft drinks?

REFERRALS Agency Date Was a referral made for developmental Y or N assessment? Was a referral made for nutritional assessment? Y or N Was a referral made to WIC? Y or N Was a referral made to Head Start? Y or N

NOTES:______

Rev. 8/16/2011 4 Please circle the specific event code(s) that occurred in this case and record the date:

Event Date Event Description Result Code Code Completed

0CNTL Contact Attempt by Letter

0IHVN Initial Home Visit by P. H. Nurse

0IHVC Initial Home Visit by Case Manager

0HVED Home Visit for Lead Education

0HVOT Home Visit for Any Other Reason

MDIEV Medical, Initial Evaluation

0MIRO Referred for iron deficiency

0MCHI Chelation, Inpatient

0MCHO Chelation, Outpatient

0RFRA Referred to Licensed Risk Assessor

0RACM Received Risk Assessment report

0HVRA Risk Assessment Completed

1FSTA Environmental Investigation for the Indiana’s 5-Star Environmental Recognition Program

0HVDA Developmental assessment conducted

0DARF Referral for developmental assessment

0HDST Headstart participant

0HSRF Referral for Headstart services

0WICP WIC participant

Rev. 8/16/2011 5 0WICR WIC referral

0HVNA Nutritional assessment conducted

0NARF Referral for nutritional assessment

Remember to fill out the Environmental Questionnaire during visit Result Codes: C - Complete; L - Could Not Locate; M - Moved; N - No One Home; O - Incomplete, Other; R - Refused

Completed By:

Date RETURN TO: Indiana Lead and Healthy Homes Program Indiana State Department of Health 2 N. Meridian Street, Section 5J Indianapolis, IN 46204-3003 317-233-1630 fax

Rev. 8/16/2011 6